Management of Enterocutaneous Fistula

P. Bernard McIntyre, M.D.

Enterocutaneous Fistula Mistakes

Not operating early enough!

Operating too early!

Question 1
Octreotide may improve success of spontaneous closure of enterocutaneous fistulas A. True B. False

Question 2
There is no need for anyone to wait greater than 12 weeks for attempt at repair of enterocutaneous fistula
A. True B. False

Question 3
Direct suture repair of exposed fistulas is futile
A. True B. False

Etiology
Malignancy Radiation Crohns Disease Post-operative ( 80% 90 % )

Management
Phase 1: Stabilization Phase 2: Anatomical definition Phase 3: Definitive operation

Stabilization
Fluid and electrolyte imbalances
Measure fistula losses & electrolyte content if high output (>500 ml) Additional HCO replacement may be needed with duodenal or pancreatic fistulas H antagonist or PPI Octreotide may reduce fistula output & shorten time to closure. No evidence to support fistula closure. May affect immune function.

Stabilization
Sepsis control
Broad spectrum antibiotics Percutaneous drainage Laparotomy if needed for source control

Nutrition
Enteral feeding, if feasible (100cm bowel distal or proximal to fistula) Parenteral feeding may be needed as supplement to enteral feeds No level 1 evidence to favor either route ? Fish oil and omega-3 fatty acids

Skin care
The stomal therapist is your friend!

Enteroatmospheric Fistula
incidence, > 50% mortality Largely preventable Avoid negative-pressure or gauze dressings directly on exposed bowel Early split-thickness or cadaver skin grafting to granulating surface Obliterative peritonitis precludes early repair (< 6 months) Effluent control difficult ( avoid tube drainage) Some success with local suturing and grafting

Effluent Collecting System

VAC System

Effluent Collecting System

Anatomical definition
Develop information to assess likelihood of spontaneous closure (15% - 71%)) Stomach, lateral duodenum, lig. of Treitz, and distal ileum all unfavorable sites Fistulograms, contrast studies, CTs may all play a role in defining anatomy Wait for established tract (>10 days) for studies

Anatomic Features Unfavourable for Spontaneous Closure

Foreign body Radiation Inflammation / Infection Epithelialization of the tract Neoplasm Distal obstruction Short tract or > 1 cm enteral defect

Definitive operation
Timing is everything! Shake test Ureteral stenting if expecting dense adhesions Enter abdominal cavity in easiest area (upper midline) Lyse adhesions from stomach to colon Repair serosal tears and enterotomies as encountered Segmental bowel resection of fistula site Component separation or skin only closure acceptable . Plastics may need to help

Severity of Adhesions
Extreme

Great

Moderate Minimal
0 7 14 21 28 42 56 84 6 months

Time after Operation

Definitive operation
Timing is everything! Shake test Ureteral stenting if expecting dense adhesions Enter abdominal cavity in easiest area (upper midline) Lyse adhesions from stomach to colon Repair serosal tears and enterotomies as encountered Segmental bowel resection of fistula site Component separation or skin only closure acceptable . Plastics may need to help.

Conclusions
ECF remains a difficult management problem, especially EAF The basis of management remains control of sepsis and fistula effluent with ongoing nutritional maintenance Early surgery should be limited to abscess drainage and proximal defunctioning stoma Definitive procedures for persistent ECF should take place several months later with resection of the fistulous segment